Form CT-5 Fillable Application for Cigarette Wholesale Dealer and/or Tobacco Distributor License
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

(Rev 7/06) * If the applicant is a corporation partnership or LLC list all persons with 10% or more ownership interest below Applicant must sign this form APPLICATION FOR CIGARETTE WHOLESALE DEALER AND/OR Cigarette Wholesale Dealer D Form CT 5 If the applicant is a corporation partnership or LLC list principal owners (ownership interest of 10% or more) Location of Accounting Records Street or Road (NO PO BOX) City State Zip Code MAIL THIS APPLICATION TO: VERMONT DEPARTMENT OF TAXES 133 STATE STREET MONTPELIER VT 05633 1401 Mailing Address Street Road or PO Box City State Zip Code Name of Applicant* Telephone Number Federal ID Number Name of Contact Person E mail address Telephone Number Physical Location of Business Street (NO PO BOX) City State Please print or type Incomplete and/or illegible applications will be returned Principal owner name Address City State ZIP Code Principal owner name Address City State ZIP Code Principal owner name Address City State ZIP Code Principal owner name Address City State ZIP Code Principal owner name Address City State ZIP Code Printed Name Title Reason for Application Signature of Applicant Date TOBACCO DISTRIBUTOR LICENSE Tobacco Wholesale Distributor Trade Name of Business VERMONT DEPARTMENT OF TAXES